Renal Disorders in Children
Hypospadias
Urethral opening of male is located below
the glans or underneath the penile shaft
Incidence 1 out of 300 live births
Cause unknown
Familial tendency
Website1 and Website 2 with hypospadias
repair
Chordee
Ventral curvature of the penis
Often accompanies more severe forms of
hypospadias
Foreskin may be absent ventrally
Hooded or crooked appearance of penis
Surgical repair
Surgical Repair of Hypospadias
Objectives of repair
◦ Enhance ability to void standing up w/straight stream
◦ Improve physical appearance of genitalia for psychological
reasons
◦ Preserve sexually adequate organ
Repair best done between 6-18 mos
◦ Before develops body image and castration anxiety
Nursing care:
◦ Prepare parents w/simple explanations
◦ Stent may be placed, but Catheter care essential–
discharge instructions
◦ Increase PO fluids
◦ Loose clothing, no straddle toys, swimming, tub baths,
rough play or sandboxes
Renal Development in Peds
Fluid larger % of total body wt.
GFR not adult level til 1-2 yrs.
Short loop of Henle in newborn
Less efficient first 2 yrs.
No bladder control first 2 yrs.
Smaller bladder capacity
◦ Newborn production about 1 to 2 mL/kg/hr
◦ Child production about 1 mL/kg/hr
Shorter urethra
Lab & Diagnostic Tests
Routine UA
Specific gravity
pH
BUN and Cr
IVP
VCUG
Ultrasounds
Angiography
Normal Urinalysis
pH 5 to 9
Sp gr 1.001 to 1.035
Protein <20 mg/dL
Urobilinogen up to 1 mg/dL
WBC’s: 0—5
NONE OF THE FOLLOWING:
◦ Glucose
◦ Ketones
◦ Hgb
– RBCs
– Casts
– Nitrites
UTI Classification
Upper Tract:
◦ Pyelonephritis,VUR
Typically causes fever, chills, flank pain
◦ Glomerulonephritis
Pink or cola-colored urine from red blood cells in your urine (hematuria)
Foamy urine due to excess protein (proteinuria)
High blood pressure (hypertension)
Fluid retention (edema) with swelling evident in your face, hands, feet and
abdomen
Fatigue from anemia or kidney failure
Lower Tract: Urethritis, Cystitis
◦ No systemic manifestations, just localized
E. coli causes about 80%
Upper and Lower Tract UTIs
Urinary Tract Infections
Typical Symptoms: (box 30-1, p. 1140 9
th
ed. Hockenberry; box
25-3, p. 1140, 10th ed.)
◦
◦
◦
◦
◦
Dysuria
Frequent urination (>q2h), foul-smelling urine
Urgency
Suprapubic discomfort or pressure
Urine may contain visible blood or sediment
(cloudy appearance)
◦ General malaise, poor feeding or appetite,
vomiting, fussiness/irritability.
Flank pain, chills, and fever indicate
infection of upper tract (pyelonephritis)
Pediatric Manifestations
Pediatric patients with significant bacteriuria
may have no symptoms or nonspecific
symptoms like fatigue or anorexia
Frequency
Fever in some cases
Odiferous urine
Blood or blood-tinged urine
Sometimes no symptoms except generalized
sepsis
Dx: Hx, PE, UA & culture
UTI Collaborative Care:
Drug Therapy—Antibiotics
Uncomplicated cystitis: short-term course
of antibiotics
Complicated UTIs: long-term treatment
◦ Trimethoprim-sulfamethoxazole (TMP-SMX,
Bactrim) or nitrofurantoin (Macrobid)
◦ Amoxicillin, Cephalexin, Gentamycin
Eliminate cause, ID contributing factors
Teaching
Enc. freq. voiding & complete emptying
↑ fluid intake
Acidify urine (cranberry juice,Vit. C)-present
research does NOT support the efficacy of this. pH needs to be at
5.0 or < in order to have a significant impact on e.coli. (P. 1145)
Avoid bubble baths, hot tubs, whirlpools
No tight panties or nylon
Good hygiene; wipe front to back
Void after sexual activity
Avoid Constipation
Vesicoureteral Reflux (VUR)
Urine swept up ureters w/each void then
empties back into bladder (p. 1269)
↑s chance for infections - most common
cause of pyelonephritis in children
Scarring by 5-6 yrs
Dx: ultrasound; cystography;VCUG
Tx: continuous low dose antibiotics
w/freq urine cultures OR surgical repair
with stent placement.
Acute Glomerulonephritis
APSGN most common – 10-14 days after
strep infection (skin or throat)
Inflammation of glomeruli; damage by antigenantibody complex
↓ GFR & renal bld flow → HTN & edema
Most common s/s: HTN—monitor regularly, edema
(periorbital), hematuria/proteinuria
Daily wt – IMPORTANT
Maintain fluid balance & treat HTN
◦ Loop diuretics or anti-hypertensives may be used
1st
sign of improvement-- ↑ urine & ↓ wt.
Nephrotic Syndrome
Glomerular injury → massive proteinuria,
hypoalbuminemia, hyperlipemia, edema
Other s/s: wt. gain, periorbital edema early
in day → ankle edema later in day,
anorexia, pallor, fatigue, oliguria (dark &
frothy)
More common between 2-4 yrs old
Compare APSGN with Nephrotic
Syndrome—see chart at end of Ppt.
Types
Most common in peds: MCNS
◦ Minimal-Change Nephrotic Syndrome
◦ 80% of cases – cause unknown
◦ Precipitated by viral URI
Secondary: result of glomerular damage
◦
◦
◦
◦
Acute Glomerulonephritis
Collagen Diseases (Lupus)
Drug toxins/poisons/venons
AIDS, sickle cell, hepatitis & others
Diagnosis of Nephrotic Syndrome
History of S/S
Labs
◦ Urine
Proteinurea >2 gm/day
Specific gravity ↑
◦ Blood
↓ serum protein
Hgb/Hct – nl or slightly ↑ due to
hemoconcentration
Platelets ↑ and serum Na+ ↓
Cholesterol ↑
Treatment
Goals: Must try to ↓ excretion of protein
& ↓ inflammation
Meds: Corticosteroids till urine is free
from protein & normal 10-14 days
◦ Immunosuppressants – Cytoxan
◦ Loop Diuretics – not always effective
During massive edema→ ↓salt
No restriction on water
Nursing Considerations
Monitor for infection (esp. peritonitis)
Monitor for side effects of steroids
Monitor wt, I & O, abd. girth
Urinalysis for albumin
Protect skin from breakdown d/t edema
VS for signs of complications
Monitor diet restrictions
Support and educate family
Prognosis
If diuresis within 7-21 days – GOOD
If not after 28 days → chance of response ↓
80% OK
50% relapse after 5 yrs
20% relapse after 10 yrs
Key: early ID and Tx
If responds to steroids, relapse is less
Manifestations
Acute Glomerular
Nephritis
Minimal Change
Nephrosis
ASO Titers
Normal
BP
Normal or
Edema
Primarily peripheral
or periorbital
Generalized, severe
Circulatory congestion
Common
Absent
Proteinuria
Mild –moderate
Massive
Hematuria
Gross or microscopic
Microscopic or none
•RBC casts
Present
Absent
Azotemia
Present
Absent
Serum K+ levels
Normal or
Normal
Serum Protein levels
Minimal reduction
Markedly
Serum lipid levels
Normal
Elevated
Peak age at onset (Yr)
5-7
2-3
0
